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Tuesday, March 10, 2015

Accident Investigations Are Error Provocative Environments

Editors – To hear more
about our thoughts on accident investigations, join us as one of our team
members presents Beyond Root Cause – A New View of Accident Investigations
at the Orange County ASSE Professional Development Conference on March 18, 2015. This week’s blog is a preview of that presentation.

A staple of the safety profession is accident investigation.
When things go wrong we marshal up the resources to figure out what happened
with the hope to prevent it from happening again. Take for example a relatively
recent injury at a client’s site, where an employee used a 21” radial saw and
had his finger amputated. Obviously this is an outcome no one wants, so the
organization organized an investigation, led by the safety professionals. In
this case the safety professionals found that the saw had a sign indicating
that the saw was “out of order”, but the employee used it anyway. While using
it, the employee shut the power down on the saw and reached toward the blade to
make an adjustment. Unfortunately the saw blade was still moving, amputating
one finger and lacerating another. The accident investigation report counseled the
organization to provide more training to employees in the shop, and to ensure
that no employees work in the shop alone. They also recommended replacing the
saw with a “safer” alternative.

One of the pioneers of the human factors field, Alphonse Chapanis, was one of the first
to identify that sometimes people make mistakes not because of deficiencies in
the person, but because of the environment they are working in. For example,
one of his early achievements was to reduce aircraft mishaps in World War II by
simply changing the design of toggle switches to make them easier to identify
what the switch was for. Simply adding a small rubber tire to the toggle switch
for landing gear reduced incidents of accidentally putting up the landing gear
to almost nothing. Chapanis, and other human factors pioneers, identified early
on that many times errors can be simply chalked up to a poorly designed
environment – i.e. an environment that is designed so that the human must
overcome their humanity in order to succeed. These environments are sometimes
called “error provocative”, because they tend to provoke errors in people
operating in that environment and simply changing the environment can go a long
way to reducing mistakes.

We submit for your consideration that accident
investigations are error provocative environments. We think that asking someone
to investigate an accident, particularly in the way accidents are commonly
investigated, is putting them into a situation where they are highly likely to
make a mistake. Consider what we are asking a person to be able to do in an
accident investigation:

Be objective. The
idea that people can be completely objective at nearly any point in their life
is simply unsupported by any empirical evidence that we are aware of. All of us
take all of our experiences, education, emotions, personality, culture, etc.
into every situation we go into in life. This all colors our perceptions of the
world we live in. Even in a highly sterilized environment, such as scientific
research, Kuhn found evidence that
our worldviews (Kuhn called them “paradigms” to represent patterns of thought
in a field) drastically affect what gets researched, what questions get asked, and
therefore, what answers are deemed acceptable by a scientific community. Note
that all of this happened without the conscious awareness of the researchers.
If this is true in scientific research, where emotion should play not part, how
can we expect objectivity in the highly emotional environment of an accident
investigation? Add to this that often we are investigating environments where
we had significant influence before the accident. As Manuele noted,
often this puts us into situations where the investigator has a vested interest
in downplaying their role. In some cases, Manuele points out, the investigator
may be writing their own performance appraisal with the investigation. How can
we expect objectivity in such an environment?

Explain the complex in
a simple waythat facilitates action.
The point of an accident investigation in the minds of most safety
professionals is to lead to action, so we can prevent the bad thing from
happening again. So the organization expects a simple explanation of what
happened that facilitates getting things fixed. The problem is that accidents
are often quite complex. Many aspects of the normal environment came together
in an unexpected way. Sure we can point to many things and say “if only this
didn’t happen then the accident wouldn’t have happened”, but where do we draw
the line. Often we end up with arbitrary stop rules on our investigations where
we just decide where to stop the investigation. Unfortunately this often leads
investigators to solving the problems they wanted to solve before the accident. So the investigation is led by the need to
solve problems, not by the need to learn.

Be thorough and
efficient. In all environments we have competing goals, but accident
investigations are hyper-examples of this. We must be thorough and really dive
into what happened, but we also have rules that require us to turn in
investigation findings within a certain time frame, so we must be efficient.
Unfortunately you can’t be both completely thorough and completely efficient.
Something has to give.

If we go back to the employee amputation we can see examples
of these problems. Upon our analysis, the accident investigation missed a lot
of really important lessons. The saw was purchased years ago and was left in
the shop, partially set up. The employees in the shop didn’t want to use the
saw because most were intimidated by the size of it. So the saw was not really
out of order, it just wasn’t completely set up, and all of the employees knew
this. One employee felt comfortable using the saw. Guess which one…

Now we do not blame anyone in the organization for any of
this, whether for the accident or for the investigation. The problem is that,
in both cases, people were put into situations that invited mistakes.
Unfortunately, the problems that led to the accident, although complex, are
easier to solve than the problems that led to an accident investigation that
missed some key learning points. As a profession, safety professionals need to
rethink the way we investigate accidents. If we just “go with our gut” and
investigate without really thinking through and challenging ourselves, we will
often come up with a poor product. We need to develop environments that
facilitate learning. Some quick examples to consider to make your
investigations better are:

Get others involved in the process whenever possible.
Diversity in the process often leads to better outcomes. This includes getting
the employees who were involved in the accident involved in the investigation,
if possible.

Use investigations as learning processes. Searching for
“the” cause may actually make the end product of the investigation worse,
because it might lead us to stop the learning process. Investigations should be
about learning, and often after an accident the organization is willing to
learn, so take advantage of them.

Start thinking in terms of systems. The old ways of
understanding organizations just can’t capture the complexity of the
organization. There’s a ton of great resources out there, such as from Meadows,
Checkland,
Leveson,
and Senge.
Find something that works for you and start the learning point today!